Counseling Cancer Patients About Changes in Sexual Function

Counseling Cancer Patients About Changes in Sexual Function

Sex is an integral component of the biomedical, psychosocial, and
Darwinian models of human behavior. With it, interpersonal
relationships are more intimate, romance is more meaningful, and life
is more fun. Without it, our species would not continue.

These principles are so fundamental to health and well-being that
their absence from the curricula of most medical schools, residency
programs, and fellowships is ironic. But this may explain why many
physicians feel ill-equipped to address issues of sexuality during
the course of routine health care and in the management of patients
with cancer.

When cancer strikes, it not only can steal time but also can detract
from individuals self-image, feelings of worth, and sense of
normalcy. All of these factors can negatively affect sexual function.
By decreasing both quantity and quality of life, cancer can tear away
years from life and life from years.

Clinicians involved in any facet of oncology must be alert to this
aspect of the cancer patients experience. Indeed, despite many
substantial gains made in the management of cancer in recent years,
care is arguably incomplete without full attention to the
patients personal response to illness, including sexual function.

In her thorough and somewhat provocative article, Dr. Schover draws
upon a career of work to implore those in the oncology community to
sharpen their diagnostic and therapeutic skills in this area. Her
plea is simple, and is easier to put into action than it may appear
at first.

Changing Perspectives on Sex With Aging

Perspectives on sex change profoundly during the course of a
lifetime. Normal aging brings with it a natural decline in sexual
function for most individuals. The Massachusetts Male Aging Study
showed that the incidence of erectile dysfunction rises threefold
between the fifth and eighth decades of life.[1] In fact, as many as
one-third of older men without cancer report experiencing a
significant impairment in sexual function.[2]

Despite these age-related changes, men may remain interested in sex
and eroticism well into old age.[3] Sometimes, an occasional morning
erection is enough for a man to maintain his self-image. Others learn
that a firm penis is not a prerequisite for a satisfying sex life.

Despite the normal age-related evolution in sexual function, sex
remains important for many. When queried hypothetically, some men
express a willingness to trade away survival time in order to
preserve or improve their sexual function.[4] However, others decline
to exchange even a very short period of time for better sexual function.[5]

Young Men With Testicular Cancer

How a man is affected by cancer or its treatments is certainly
informed by age, perception of cure, and type of therapy. For
example, in young men with testicular cancer, sexual function may be
impaired due to altered body image, despite normal erections. Rieker
et al[6,7] showed that these patients experienced distress over
performance and infertility, although not over libido. Those with
ejaculatory dysfunction noted more strained intimate relationships
and more psychological problems. However, compared to healthy
controls, testis cancer patients, as a group, did not reveal any more
difficulty with relationships or overall mental outlook.

Bloom et al[8] compared a population of men treated for testicular
cancer with an aged-matched population treated for Hodgkins
lymphoma. Those with testicular cancer were significantly more likely
to report decreased sexual enjoyment. They were also more likely than
the lymphoma group to report their health as excellent, however,
leading the authors to conclude that the response to testicular
cancer is more site-specific.

Older Men With Prostate or Bladder Cancer

Conversely, in older men with prostate or bladder cancer, sexual
function may be impaired to a greater extent by physical erectile
dysfunction.[9,10] Mansson and colleagues[11] studied patients
undergoing cystectomy, comparing those who underwent reconstruction
with a continent cutaneous ileocecal diversion with those who had a
simple conduit diversion. Men in both groups suffered equivalent
declines in health-related quality of life related to sexual
problems, disturbed partner relationships, and emotional dysfunction.

Other researchers have shown that such decreases in disease-specific
domains can be reversed with treatment of the erectile dysfunction by
placement of an inflatable penile prosthesis.[12]

In the current era of widespread screening for prostate cancer, many
patients are diagnosed with early-stage tumors that are managed
aggressively and presumed curable. This approach may come with a
great human cost in terms of sexual function. With patients diagnosed
at ever younger ages, the quality-of-life impairments often
associated with treatment may have a long-lasting impact. The
popularity of nerve-sparing prostatectomy for men (and also
breast-conserving surgery for women) attests to the great interest in
this topic.

Discussing Sexual Issues With Patients

Some contend that two questions in the minds of all patients during
all clinical encounters are, Is it cancer? and Can
I still have sex? While this statement may seem to be
hyperbolic, physicians typically do overlook at least one of these
issues that weigh so heavily on our patients minds.

As Dr. Schover correctly points out, we are often too embarrassed to
bring up a topic we perceive as delicate. Yet, our own anxieties
about talking about sex generally exceed those of our patients.
Often, all that is required is to broach the topic, allow patients a
safe environment in which to vent their fears, and provide the
reassurance that they need (see Case Report). In so doing, we are
treating the whole patient and not just the cancer.

Case Report: Broaching the Subject of Sexuality

Recently, a 56-year-old man came to me for a second opinion on a
moderately high-grade prostate cancer that had been diagnosed almost
9 months previously. His general health was excellent, and he had
been strongly encouraged by his primary urologist to undergo a
radical prostatectomy.

Although the patient was leaning toward that option, he remained
terrified of the risk of impotence. Despite a competent evaluation by
the urologist and a thoughtful recommendation from his primary care
doctor, both physicians had overlooked an important component of the
patients sexuality. Because he had never married and did not
speak of a partner, he was assumed to be relatively unconcerned about
sexual function.

By addressing sex in gender-neutral terms, I was able to determine
that the patient was, indeed, involved in a long-term romantic
relationship with a younger man and was quite concerned about his
ability to function after surgery. He had not even told his partner
about his diagnosis, and yet he had been carrying around the anxiety
for almost a year.

In an open, nonjudgmental environment, the patient began to feel more
comfortable discussing his sexuality. With some encouragement, he
returned with his partner for a follow-up visit and ultimately
decided to undergo surgery. The patient later wrote a heartfelt
letter of appreciation thanking me for helping him resolve his sexual
concerns and reach a decision about treatment.

Clinicians also often overlook the sexual concerns of the young,
single adult with cancer, such as the young man with testis cancer,
young woman with breast cancer, or teenager with lymphoma. Given
their lack of experience and self-confidence, these individuals may
be even more reticent to bring up the topic of sexuality with their oncologists.

It is especially incumbent upon the clinician to talk about sex with
the young adult with cancer, before, during, and after treatment. For
such individuals, the difficult questions may be, Should I tell
a new romantic interest about the cancer on the first date, or should
I wait? Of course, these problems are relevant for the single
patient of any age.

As Dr. Schover points out, a sensitive, open-minded, and forthright
attitude about issues of sexual function is always appropriate when
caring for patients with cancer. While a multidisciplinary team
approach may be more efficient, sexual counseling often can be
carried out very effectively with a relatively small investment of
time by the oncologist. Referral for further intervention can still
be made available for patients who need it.

Cancer affects quantity and quality of life. The challenge for
oncologists is to address both components with compassion.